IACAPAP Textbook of Child and Adolescent Mental Health

Section F

ANXIETY DISORDERS

Associate Editors: Ana Figueroa & Cesar Soutullo

Photo: D Sharon Pruitt, Wikimedia Commons

 IACAPAP Textbook of Child and Adolescent Mental Health
Chapter
ANXIETY DISORDERS F.1
ANXIETY DISORDERS IN
CHILDREN AND ADOLESCENTS
NATURE, DEVELOPMENT, TREATMENT
AND PREVENTION

Ronald M Rapee

Ronald M Rapee PhD

Professor, Centre for
Emotional Health, Department
of Psychology, Macquarie
University, Sydney, Australia
Conflict of interest: receiving
royalties from the book,
Helping your Anxious Child:
A Step by Step Guide for
Parents. Proceeds from sales
of the Cool Kids program go to
the Centre for Emotional Health
at Macquarie University to
assist research and treatment
for anxious children – no
individual receives any income
from these materials.

Monsters, Inc® Pixar

This publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks to
describe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authors
and may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines and
laws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
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©IACAPAP 2012. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
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the use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Rapee RM. Anxiety disorders in children and adolescents: Nature, development, treatment and prevention. In
Rey JM (ed), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent
Psychiatry and Allied Professions 2012.

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I
t was not very many years ago that anxiety disorders in children were thought
to be relatively rare and low impact conditions. As a result our empirical
knowledge about child anxiety is less extensive than it is for the adult
conditions. Nevertheless, the past 15 to 20 years have seen a dramatic increase in
the number of studies examining child anxiety and we are now building a good
understanding of the nature, development and treatment of these disorders. Even
more recently interest has started to focus on possible prevention of anxiety and,
given the overlap between anxiety and depression as well as the continuity from
childhood into adulthood, this work has far-reaching implications for prevention
of internalising difficulties right across the lifespan.
Compared with research in the adult realm that tends to split disorders
very specifically, within the child and adolescent fields, there is a more common
Internalising
tendency to examine anxiety relatively broadly and in many cases to examine disorders
internalising disorders as a whole. Therefore, in the current chapter, I will talk
about anxiety disorders in most cases very broadly and consider factors relevant As opposed to
“externalising” or
to all the anxiety disorders as a group. This is especially the case for treatment,
“undercontrolled” disorders”
where most empirically supported psychological packages have tended to include (such as conduct disorder)
children across the range of anxiety disorders. However, given that other chapters in which children tend
in this book focus on obsessive compulsive disorder, post-traumatic reactions and to externalize or act out
inner conflict or emotions
separation anxiety, I will focus, where possible, more directly on the remaining (e.g., through aggression)
disorders, generalised anxiety, social anxiety and specific phobias. To reduce – internalizing disorders
repetition, I will generally use the terms child anxiety or childhood anxiety to refer reflect problems within
to anxiety in both children and adolescents, unless specific age distinctions are the self, such as fears,
worrying and unhappiness,
necessary. traditionally subsumed
under the rubric of
DESCRIPTION AND DIAGNOSIS “neuroses”, "overcontrolled"
or “overinhibited" problems.
The core feature of anxiety disorders is avoidance. In most cases this
Children with internalising
includes overt avoidance of specific situations, places, or stimuli, but it may also disorders tend to deal with
involve more subtle forms of avoidance such as hesitancy, uncertainty, withdrawal, problems and emotional
or ritualised actions. These behaviours are relatively consistent across disorders and conflict internally rather
than acting them out.
the key difference between specific disorders is the trigger for this avoidance. The Internalizing disorders
avoidance is generally accompanied by affective components of fearfulness, distress usually cause more distress
or shyness. Some children, however, especially younger ones, may have difficulty to the child than to those
verbalising these emotions. Anxiousness occurs due to an expectation that some around them, the opposite
of what happens with
dangerous or negative event is about to occur - in other words an expectation of externalizing disorders.
threat. Therefore, in identifying the anxious child, it is crucial to determine that
the avoidance occurs due to an expectation of some sort of threat. For example,
two children may say that they do not want to go to school. In one case this
appears to be due to the fact that they are having more fun going to the shops with
their friends, while in the second case it appears to be due to a belief that other
children are making fun of the child. Even though both may superficially seem to
be avoiding school, the former case would not reflect anxiety since the behaviour
is not motivated by a perceived threat. All of the anxiety disorders will involve
an anticipation of threat, which may take the form of worry, rumination, anxious
anticipation, or negative thoughts. The key differences between disorders lie in the
content of these beliefs as will be described below. In addition to the described
beliefs, behaviours, and emotions, anxious children will often report a range of
associated physical complaints reflecting heightened arousal; however, these are rarely
specific to a given disorder and hence are rarely diagnostic. Physical symptoms that

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Table F.1.1 Core and associated features of the various anxiety disorders.
DISORDER CORE FEATURES
Separation anxiety Fear or concern that
disorder something bad will happen
to the child or attachment
figure (commonly a parent)
when they are separated.
As a result of this belief, the
child avoids separation from
the attachment figure.
Generalised A tendency to worry about
anxiety disorder a wide range of negative
possibilities, that something
bad will happen
Social phobia Fear and avoidance of
social interactions or social
performance due to a belief
that others will negatively
evaluate the child
Specific phobias The core feature of specific
phobias involves fear and
avoidance in response to
a range of specific cues,
situations, or objects. There
is a common belief that the
object or situation will lead
to personal harm
Panic Disorder and agoraphobia*
Panic Disorder Experience and fear of
unexpected panic attacks,
commonly involving several
somatic symptoms and
fears of dying or going
crazy.
Agoraphobia Agoraphobia involves
an additional fear and
avoidance of several
"agoraphobic" situations,
commonly due to a fear of
experiencing a panic attack
in those situations.
* Both panic disorder and agoraphobia have their mean age of onset in early adulthood and hence are rare in childhood. Only
occasional cases occur prior to 15 years and small numbers will begin to present from 15 to 18 years.
Anxiety disorders F.1
ASSOCIATED FEATURES
• Dreams or nightmares about separation
• Refusal to face situations that involve separation, including
sleeping away from home, going to school, visiting friends or
relatives, staying at home alone or with child minders
• Worry about the consequences of separation including fears of
being kidnapped or injured or of the attachment figure being hurt,
or killed while apart
• Physical symptoms when separation is anticipated including,
vomiting, diarrhoea, and stomach aches
• Repeated and extensive worry about several areas such as family
finances, friendships, schoolwork, sports performance, self and
family health, and minor, daily issues.
• Tendency to repeatedly seek reassurance from parents or others
about fears.
• Avoidance of novelty, negative news, uncertain situations, and
making mistakes.
• Physical symptoms, sleeplessness and irritability when worried.
• Avoidance of a range of social activities or situations including,
speaking or performing in front of others, meeting new children,
talking to authority figures such as teachers, being the centre of
attention in any way, and for teenagers, fears of dating
• Worries about negative evaluation from others including that
others will think they are unattractive, stupid, unpleasant, overly
confident, or odd
• A limited number of friends and difficulty making new friends
• High levels of self-consciousness or self-focussed attention
Some common fears in children include:
• Animals such as dogs or birds
• Insects or spiders
• The dark
• Loud noises and especially storms
• Clowns, masks, or unusual looking people
• Blood, illness, injections
• Several somatic symptoms that usually peak relatively quickly and
last for a specific period
• Symptoms commonly include palpitations, breathlessness,
dizziness, trembling, and chest pain
• At least some attacks occur unexpectedly or "out of the blue"
• Avoidance of situations due to fear of symptoms or their
consequences
• Common agoraphobic situations include places from which quick
escape is difficult such as public transport, enclosed spaces,
cinemas, hairdressers, or heavy traffic.
• There is a common reliance on specific safety cues, commonly a
safe attachment figure.
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are common among anxious children include: headaches, stomach aches, nausea,
vomiting, diarrhoea, and muscle tension. In addition, it is common for many
anxious children, especially those that worry considerably, to have difficulty with
sleep.
As mentioned, the key differences between specific anxiety disorders
involve the particular triggers for the anxiousness, the situations that are avoided,
and the content of the beliefs, as shown in Table F.1.1. Separation anxiety and
school refusal are described in detail in Chapter F.2.
Other anxiety disorders
Social anxiety
As mentioned previously, other anxiety disorders are covered in their own It should be noted that
chapters and hence will be addressed only briefly here. Children with obsessive socially anxious children
compulsive disorder (OCD) report repetitive and intrusive thoughts, images or urges, are not necessarily poor
in social skills. They are
often accompanied by repeated characteristic actions or behaviours with the goal commonly ignored or
of reducing anxiety. The mental components commonly focus on some expected neglected rather than
threat or danger (hence it is an anxiety disorder), although some forms of OCD rejected. However, as a
may fail to report threat expectations and may focus more on a sense of disgust result of their anxiety, they
may sometimes act in a
and a belief that certain actions simply "feel right". When a threat expectation socially awkward manner
does exist, the corresponding rituals are generally aimed at preventing or undoing and may perform poorly
the expected danger. In children, the picture is complicated by the fact that many in social situations. For
children, especially younger ones, are unable to clearly report on their beliefs and example they may not
speak very much or may
motivations. Among children, the most common rituals involve washing and fears talk very quietly, they may
of contamination, and checking or ordering and fears of catastrophe if certain show poor eye contact, or
actions are not adequately performed. they may talk in a hesitant
and uncertain manner.
Post traumatic stress disorder involves a constellation of symptoms of
heightened arousal (e.g., jumpiness), intrusions (e.g., distress on reminders of the
trauma), detachment (e.g., trouble remembering aspects of the trauma, numbness
and flatness), and avoidance that occur following a severe (life threatening) event.
Although, sadly, many children in our world experience life threatening events, post
traumatic stress disorder is relatively infrequent in childhood (Rapee et al, 2009).
Some authors have argued that this is because the criteria are not sensitive to the
presentation among children, while others suggest that it may reflect the reduced
sense of past and future in children's cognitive development. Post traumatic stress
disorder is discussed in detail in Chapter F.4.
School refusal
Although school refusal is not a formal diagnosis in either the DSM or
ICD, a brief mention is warranted here due to its common discussion in various
circles. There is little doubt that many children do not wish to attend school and
in a small percentage of cases they may not attend for lengthy periods. This is
often referred to as school refusal. School refusal is not an anxiety disorder and
may be motivated by many factors aside from anxiety, but when it occurs, anxiety
is a common underlying element. However, anxiety alone is not a sufficient
explanation. School refusal involves both a motivation from the child to not
attend school (sometimes due to anxiety) combined with a social and usually
parental acquiescence to this demand. Naturally, this latter component will vary
between societies depending on the laws for school attendance, social norms, and
parental needs (such as extreme poverty). However, where laws and norms provide

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an expectation for school attendance (such as in most Western countries), school

refusal commonly involves some difficulty within the family or at least one parent.
For example, in some cases school nonattendance is partly encouraged by a parent
who may wish the child to help with their own needs (e.g., a physical or mental
disability) or the parent / child relationship may become pathological due to severe
marital difficulties, and so on. In other words, chronic school refusal may reflect
a variety of anxiety (or other) difficulties within the child (e.g., fear of the school
work, separation anxiety, social fears, bullying, etc) combined with parental or
family difficulties and in some cases with social support for nonattendance (see
Chapter F.2 for further discussion).
Comorbidity
As mentioned earlier, it is common for discussions of childhood anxiety
to focus broadly across anxiety (and sometimes related disorders) rather than
focussing on only a single disorder. One of the main reasons for this is the strong
overlap between anxiety disorders and between anxiety and other internalising
disorders, especially depression. Clinically anxious children rarely meet criteria
for only one disorder. Within treatment-seeking populations, around 80% to
90% meet criteria for more than one mental disorder. The majority, up to 75%,
meet criteria for more than one anxiety disorder. A further 10% to 30% also
meet criteria for an additional mood disorder. Age differences are apparent here
– around 30% of treatment-seeking adolescents meet criteria for an additional
mood disorder while only around 10% to15% of younger anxious children do so.
About 25% of younger treatment-seeking anxious children will also meet criteria
for an additional behavioural disorder. Similar figures are found in population-
based samples, although the proportion of children with a single anxiety disorder
is slightly higher. Nevertheless, even in population based samples, children with
anxiety disorders are markedly more likely to have additional anxiety, mood, and
behavioural disorders. Interestingly, anxious children do not appear to be at greater
risk for substance abuse, most likely reflecting the fact that these children generally
obey rules and do not take risks. The overlap between anxiety disorders and alcohol
abuse does not appear until late adolescence or early adulthood (Costello et al,
2003).
EPIDEMIOLOGY
Prevalence
Prevalence estimates of child anxiety have been somewhat variable
across countries and studies due to many factors including variations in criteria,
assessment instruments and sampling. Overall, around 5% of children and
adolescents meet criteria for an anxiety disorder during a given period of time in
Western populations (Rapee et al, 2009). There is little data available from other
cultures, but one study from Puerto Rico has shown similar rates (Canino et al,
2004). In most studies prevalence is highest for specific phobias and moderate for
separation anxiety, generalised anxiety and social phobia. Considerably lower rates
are reported for obsessive compulsive disorder and the lowest rates are reported for
post traumatic stress disorder.
Gender distribution
Anxiety disorders are more common in females than males in the general

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population. Most population studies estimate around 1.5-2 times as many females
compared to males for most anxiety disorders. There is some evidence that this
gender difference appears very early – as young as 5 years of age. In contrast,
distributions within treatment-seeking samples in Western societies are more equal
and even include slightly more males.
Age of onset
Anxiety disorders are among some of the earliest disorders to appear
and most commonly begin by middle childhood to mid adolescence. As will be
discussed later, it is common for anxiety disorders to appear within a context of
temperamental inhibition (see below) and fearfulness. Hence it is often difficult to
determine exactly when the actual anxiety disorder first begins and, to some extent,
anxious children can often be said to be anxious from birth. However, estimates
of average age of onset (these are averages, disorder can start earlier in individual
cases) for the different disorders are as follows:
• Animal phobias – early childhood (around 6-7 years)
• Separation anxiety disorder – early to mid-childhood (around 7-8
years)
• Generalised anxiety disorder – late childhood (around 10-12 years)
• Social anxiety disorder – early adolescence (around 11-13 years)
• Obsessive compulsive disorder – mid adolescence (around 13-15
years)
• Panic disorder – early adulthood (around 22-24 years)
Course
Anxiety disorders are among the most stable forms of psychopathology
and show relatively little spontaneous remission. Anxious children are also at
increased risk of developing other disorders during adolescence and into adulthood.
Longitudinal research has shown that anxious children are at significantly greater
risk for anxiety and mood disorders in adolescence and for anxiety, mood, and
substance use disorders as well as suicide in adulthood (Last et al, 1997; Pine et al,
1998).
Other demographic features
Interestingly, anxiety in childhood is characterised by very few demographic
risk factors. There is some evidence that low socioeconomic status might provide
some risk for anxiety but the data are mixed and the degree of risk is small. Similarly,
some research has hinted that socially anxious children in particular are more likely
to be first born but other research has failed to support this finding. Most other
demographic characteristics fail to predict anxiety. Hence anxious children are not
characterised by family size, parental marital status, educational attainment or
intelligence (Rapee et al, 2009).

ASSESSMENT
Clinical evaluation generally includes a combination of questionnaires,
diagnostic interview and behavioural observation. However, in most clinical
settings, a diagnostic interview and a small number of questionnaires will be most

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appropriate.

Diagnostic interview
Several structured diagnostic interviews exist to assist in determining
either DSM or ICD criteria for childhood disorders including anxiety. Most
interviews include a large number of questions aimed to tap each of the relevant
diagnostic criteria and generally differ in their degree of structure. Some widely
used instruments include:
• Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS)
• Development and Wellbeing Assessment (DAWBA)
• Diagnostic Interview Schedule for Children (DISC)
If the interest is in anxiety more specifically, then the Anxiety Disorders
Interview Schedule for Children (ADIS-C) (Silverman & Albano, 1996) has
a primary focus on these disorders. For very young children, the Preschool Age
Psychiatric Assessment (PAPA) is a useful instrument (Egger et al, 2006). Most
structured interviews involve separate interviews with the parents and the child (at
least once the child is 8 years old or so) and the clinician is then faced with the task
of combining the information in some way.
Like most disorders of childhood, information from parents and children
about anxiety disorders commonly contains several discordant aspects. Clinical
judgement and experience needs to be applied to determine which information
is more heavily weighted and how best to combine the information (see Chapter
A.3 for a detailed discussion of this issue). Anxious children are often thought to
“fake good" (Kendall & Chansky, 1991) – in other words, to deny feeling anxious
or to provide answers that they think are socially acceptable. However, many
parents are also anxious (discussed below) and in some cases will exaggerate the
child's difficulties due to their own distress. Hence, the interviewer needs to obtain
sufficient detail to allow a judgement about which is the most accurate report and
which aspects of the information may be inaccurate for various reasons.
Clinically, distinguishing between specific disorders can be difficult.
As described above, it is important to determine the basic motivation behind
particular behaviours in order to identify the relevant diagnosis. For example,
young children who have a tantrum when their parents plan to go out may be
doing so due to the attention and subsequent rewards they receive, or to fear
of being separated. Clinically, once all behaviours, motivations, and diagnostic
criteria have been assessed and it has been determined that a child meets criteria for
two (or more) clearly distinct disorders, it is generally useful to determine which
of the disorders is primary or principal. Most authors conceptualise the principal
disorder as the one that produces the greatest impact and interference in the
child's life. Hence this disorder is usually the first focus in therapy. Most empirical
evaluations of treatments for child anxiety are based on children who meet criteria
for anxiety disorders as their principal disorder. In some cases however, it may be
more important to determine which disorder appears to be the underlying or causal
problem. For example, a child suffering depression, loneliness and victimisation
because of their social anxiety may respond best if the social anxiety is treated
first, regardless of whether it is the primary condition. In some cases, a particular

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problem may be expected to interfere with treatment response and may therefore
require initial attention, even if it is not the principal disorder. For example, a child
whose anxiety appears to be most interfering but whose additional depression
results in low motivation may need treatment addressed to the depression and
motivation before they will be able to engage in treatment for the anxiety.
Questionnaire assessment of child anxiety
The severity of anxiety or extent of anxiety symptomatology can be
measured using several well developed questionnaires. Most of these measures
have demonstrated good psychometric properties from around age 8 or 9 years
and can be used up to middle or late adolescence. From middle adolescence, adult
measures of anxiety are usually suitable. Very few measures have been developed
for younger children.
A few questionnaires contain several subscales that each tap diagnostic-
like constructs such as separation anxiety, social anxiety or generalised anxiety.
Most of these questionnaires have parallel versions for the parent and child. These
include: Click on the picture to view
• Spence Children's Anxiety Scale (SCAS) (free of charge) the Centre for Emotional
Health’s website from
• Screen for Anxiety and Related Disorders (SCARED) where the CATS, SAS-TR,
• Multidimensional Anxiety Scale for Children (MASC) and CALIS, as well as the
PASR can be downloaded
A similar measure has recently been developed for preschool-aged children, free of charge. Some of
to be completed by their parents only – the Preschool Anxiety Scale, Revised (PAS-R) these scales are available
(free of charge and available in several languages). in languages other than
English.
Several older measures aim to assess the overall degree of anxiousness more
broadly. These include:
• Revised Children's Manifest Anxiety Scale (RCMAS)
• State Trait Anxiety Inventory for Children (STAIC)
• Beck Anxiety Inventory for Youth
A similar measure assessing internalising symptomatology completed by
parents has also been developed for children at preschool age – Children’s Moods,
Fears and Worries (Bayer et al, 2006).

In some circumstances, more specific and detailed assessment of a

particular form of anxiety may be required. In these cases, a few measures tap into
specific aspects of anxiety including:
• Fear Survey Schedule for Children Revised (FSSCR)
• Social Phobia and Anxiety Inventory for Children (SPAIC)
• Social Anxiety Scale for Children - Revised (SASC-R)
• Children’s Anxiety Sensitivity Index (CASI) (Silverman et al, 1991)
Finally, a few measures from our own centre may be of value since they
tap relevant aspects related to anxiety disorders. The Children's Automatic Thoughts
Scale (CATS) is designed to assess specific beliefs experienced by children and
adolescents with a variety of disorders. Two of the subscales are especially relevant
to anxiety: beliefs related to social threat and physical threat. The remaining
subscales assess beliefs related to personal failure and hostility. The School Anxiety

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Scale -Teacher Report (SAS-TR) provides a measure of children's anxiety that can be
completed by the classroom teacher. This measure therefore provides an additional
source of information that can flesh out a broader clinical picture of the anxious
child. Finally, the Children’s Anxiety Life Interference Scale (CALIS) provides two
parallel measures (one reported by the child and the other by his/her parents) that
assess the extent to which the child's anxiety impacts on the child's and family's
life.

RISK AND MAINTAINING FACTORS

Family transmission
Anxiety runs in families. First degree relatives of people with anxiety
disorders are at significantly increased risk to also have anxiety as well as mood
disorders. The same is true more specifically for anxiety in children and adolescents.
Anxious children are considerably more likely to have parents with anxiety disorders
and adults with anxiety disorders are more likely to have anxious children (Rapee
et al, 2009). A similar relationship occurs more generally for temperament that is
related to anxiety (see below). Adults with anxiety disorders are more likely to have
children who are highly inhibited and inhibited children are more likely to have
parents with anxiety and mood disorders (Rosenbaum et al, 1993).

One important finding is that family transmission of anxiety seems to

show some specificity. In other words, several studies have shown that people
with a particular anxiety disorder (e.g., social phobia) are more likely to have first
degree relatives with that same disorder (social phobia) than with other anxiety
disorders. This is different from research on genetic factors that has not shown
specificity (see below). Of course family transmission can reflect both genetic and
environmental influences, so it is tempting to speculate that genetic transmission
confers a broad, general risk, while family environment may shape that risk into
specific manifestations.

Genetic factors
There is little doubt that anxiety disorders are heritable. Best estimates
suggest that around 40% of the variance in anxiety symptoms and in diagnoses
of anxiety disorder is mediated by genetic factors. This estimate is even higher if Jerome Kagan, professor
one looks at stability of anxiety over time. Slightly less research, but with similar of psychology at Harvard
findings, has been done on anxiety specifically during the childhood years. Twin University, is one of the
scholars who contributed
studies of anxiety in children indicate that around 30% to 40% of the variance to developing the concept
in symptoms and disorders can be attributed to heritability (Gregory & Eley, of temperament, which
2007). There is some evidence (albeit with limitations) that heritability estimates he defined as stable
for temperamental risk for anxiety (e.g., inhibition) is slightly higher (Rapee & behavioural and emotional
reactions that appear early
Coplan, 2010). As mentioned above, genetic risk across anxiety disorders appears in life. He described two
to be largely general and seems to primarily load on a very broad factor such as types of temperament:
general neuroticism (Gregory & Eley, 2007). inhibited and uninhibited.
The former applies to
Work on specific genes underlying anxiety disorders is less extensive and, children who are shy,
timid, socially withdrawn
to date, no evidence exists linking any individual gene specifically to anxiety. Many
and fearful, while the latter
candidates have been explored; the most widely studied being the promoter region refers to children who are
of the serotonin transporter gene (5HTTLPR). However, polymorphisms on this outgoing, sociable and
gene have been associated with different disorders and it is unlikely that it would daring.

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play a specific role in anxiety. In fact, one theory states that having two short
alleles on the 5HTT gene may increase an individual's overall responsiveness to
environmental events (both positive and negative) (Belsky et al, 2009).
Temperamental factors
Temperamental risk for anxiety is probably the best studied and most
clearly established risk factor (Fox et al, 2005; Rapee et al, 2009). A variety of similar
temperaments have been associated with child anxiety including: behavioural
inhibition, withdrawal, shyness and fearfulness. I will refer to these various
temperaments in this section under the general term inhibition. Extensive research
It seems that fear of
has shown that very young children who are identified as high on inhibition are strangers can be increased
at greater risk for later anxiety disorders. As described above, research has also through an interaction
linked inhibition with anxiety disorders in first degree relatives. The most common between the infant's
temperament and the
assessment of inhibition occurs in children from around 2-5 years of age. This may mother's overt indicators of
be done via questionnaires or direct observation. Common features of inhibition fear.
include:
• Withdrawal in the face of novelty
• Slowness to warm up to strangers or peers
• Lack of smiling
• Close proximity to an attachment figure
• Lack of talk
• Limited eye contact or "coy" eye gaze
• Unwillingness to explore new situations.
Children who show these characteristics during preschool age are 2-4
times more likely to meet criteria for anxiety disorders by middle childhood and
this increased risk has been shown to continue at least into adolescence (Fox et al,
2005). Some evidence has also indicated that infants (aged 3-6 months) who show
high levels of arousal and emotionality are at greater risk to show high inhibition
by 2-5 years. Therefore, it seems to be possible to identify increased risk for anxiety
from a few months of age (Kagan & Snidman, 1991).
Theoretically the main complication with this research is the extensive
overlap between the constructs of inhibition and anxiety disorders. Thus one could
argue that inhibition is simply a less clear version or an early manifestation of an
anxiety disorder. There is some evidence that inhibition and disorder have some
unique features and thereby represent distinct constructs, but the issue is far from
settled (Rapee & Coplan, 2010).
Parent and family factors
Given the evidence for the transmission of anxiety within families described
above, it has commonly been assumed that parents and the family environment
must contribute to the development of anxiety disorders. However, evidence has
been difficult to obtain and data have not been entirely consistent. The most
extensive research has focussed on parenting and parent-child interactions.
There is now little doubt that the parenting of anxious children is
characterised by overprotection, intrusiveness and, to a lesser extent, negativity
(McLeod et al, 2007). Whether this relationship is causal is much harder to
determine and, to date, there has been very little examination of this issue. Theories

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argue that the parent-child relationship is likely to reflect cyclical interactions. That
is, inhibited children are likely to elicit overprotection from their parents and,
in turn, overprotective parenting is likely to lead to further anxiety (Hudson &
Rapee, 2004; Rubin et al, 2009). Few longitudinal studies have addressed this
relationship, but at least some evidence is consistent with this theory (Edwards et
al, 2010). There is also some evidence that an interaction between the serotonin
transporter gene and parenting predicts later anxiety in young children (Fox et al,
2005).

It has often been assumed that anxious parents increase risk for anxiety
in their children by modelling their own fears and coping strategies. This theory,
however, has received very little examination. The main research has come from
laboratory studies with very young children. Research has shown that children aged
around 6-18 months can learn to fear and avoid a novel stimulus by observing their
mothers acting in a fearful manner. More importantly, socially anxious mothers
have been shown to transmit a fear of strangers to their infants in this way, and
the extent of fear that the infant develops depends partly on the pre-existing level
of inhibited temperament that the infant displays (de Rosnay et al, 2006). Thus it
seems that fear of strangers can be increased through an interaction between the
infant's temperament and the mother's overt indications of fear. Among older
children it has been shown that verbally transmitted information about danger
can increase fear of particular cues. For example, when children are presented with
information about a novel cue that suggests the cue might be dangerous, they show
increases in fear, physiological arousal, threat beliefs, and avoidance of the cue that
can last for several months (Field, 2006).

Finally, a key question is whether disturbed family environments play a

role in the development of child anxiety. There has been a wealth of longitudinal
research examining the long term impact of family distress and violence, parent
divorce or separation, and sexual and physical abuse, although little of this work
has focussed clearly on anxiety disorders. Overall, it appears that sexual abuse –
and to a lesser extent physical abuse and family violence – can increase anxiousness
in children. However, this increase is likely to be temporary and it is not clear
whether these factors contribute significantly to the development of longer-term
anxiety disorders. More importantly, it is clear that these factors are relatively non-
specific and increase risk for a wide variety of child psychopathology, probably least
of all anxiety disorders (Rapee, in press).

Life events
Although there has been a large body of research examining the role of
negative life events in the onset of adult anxiety disorders (mostly agoraphobia),
there has been very little work looking at life events in childhood anxiety. This may
be because child anxiety often develops in a background of inhibited temperament
and a clear and sudden onset to the disorder is relatively rare. What research has
been conducted suggests that anxious children do report a greater number and
impact of negative life events than do children without anxiety disorders. While
it is possible that this difference reflects cognitive and reporting biases, at least Click on the picture to hear
some work has demonstrated this difference using interviews with parents and Eli R Lebowitz PhD talk about
CBT for childhood anxiety
identifying corroborating evidence (Allen et al, 2008). Nevertheless, demonstrating
disorders (13:14 minutes)
that anxious children have more negative life events than non-anxious children

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does not mean that these events necessarily cause or trigger their anxiety. Indeed
the data suggest that the greatest difference is found on so-called "dependent" life
events. Dependent events are ones that might be the result of the child's behaviour
(e.g., doing badly in a test might be a result of the child not studying). Thus it is
very possible that child anxiety leads to more negative life events, perhaps due to
the worry and avoidance associated with the anxiety. Of course it is also possible
that this increased stress, in turn, helps to maintain and even increase the anxiety.

One specific form of life event that has received particular attention is
bullying and teasing. There is considerable evidence that anxious children are more
likely to be teased and bullied than non-anxious children and that they are often
Results indicate that 50%
neglected or even rejected by their peers (Grills & Ollendick, 2002). Once again to 60% of children are
the direction of causation is unknown but it is very likely that anxious children considered diagnosis-free at
elicit teasing from others due to their behaviours; in turn, it is likely that teasing the end of treatment (skills-
will further enhance their anxiety. based or CBT programs)
and this figure typically
Cognitive biases increases to 70%-80% up to
12 months following the end
Anxious children report heightened threat beliefs and expectations. To of treatment
some extent this is a reflection of the diagnosis, but it is also argued to represent a
core maintaining feature. Although there is considerable overlap, to some extent
the threat expectancies are specific. That is, socially phobic children are more likely
to have increased expectancies for social threat (e.g., “other kids won't like me”),
children with separation anxiety will have increased expectancies for physical
threat (e.g., “my parents will get hurt”), and so on. Evidence suggests that these
threat beliefs are greater among anxious children than among children with other
psychopathology and that they decrease with successful treatment (Schniering
& Lyneham, 2007). Whether they are causally related to the onset of anxiety or
simply reflect the anxiousness is not clear.
More recent research has also begun to focus extensively on the ways in
which anxious children process threatening information (Hadwin et al, 2006). As
has been shown in adults, anxious children have both a bias in attention toward
threat and a bias to interpret ambiguous information in a threat-consistent manner.
Some research has shown that these biases decrease with successful treatment.

TREATMENT
Psychopharmacology

Pharmacological management of anxiety in children has typically focussed

on the use of selective serotonin reuptake inhibitors (SSRIs). Some earlier research
utilising tricyclic antidepressants focussed on OCD and is covered in Chapter F.3.
Several studies have demonstrated significant efficacy of SSRIs such as fluoxetine,
sertraline, and paroxetine in the management of broad-based anxiety disorders,
although most studies have primarily focussed on treatment of OCD (Ipser et
al, 2009). Little difference has been shown between specific agents, although
paroxetine is not recommended in this age group. Treatment has generally lasted
10-15 weeks. Outcome results indicate that 50% to 60% of children are considered
treatment responders at the end of treatment compared with around 30% of those
on placebo. Unfortunately, the longer term maintenance of gains has rarely been
investigated, but there is some hint in the literature that medication effects may

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level off after around 8 weeks (Ipser et al, 2009). Adverse medication events are
relatively infrequent but do occur significantly and up to 7% of anxious children
on SSRIs discontinue due to side effects. Suicidality needs to be monitored in all
young people taking an SSRI (for more details on pharmacological treatment see
Chapter A.8 and Table A.8.1).

Skills-based programs

Most evidence-based psychological treatment for childhood anxiety falls

under the broad category of cognitive-behavioural or skills-based treatment. The
fundamental basis is teaching the child (and sometimes the parents) specific skills
to help manage the child's anxiety. Most treatments comprise comprehensive
packages or combinations of techniques. Specific treatment techniques include:
• Psychoeducation
• Relaxation
• In vivo or imaginal exposure
• Contingency management
• Parent training
• Cognitive restructuring
• Social skills and assertiveness training

Treatment programs typically last 8-15 weeks of around 1-2 hours per
session and have been delivered in either group format or individually. Results
indicate that 50% to 60% of children are considered diagnosis-free at the end
of treatment and this figure typically increases to 70%-80% up to 12 months
following the end of treatment (James et al, 2006). A few studies have indicated
maintenance of treatment gains up to 6-8 years following treatment (e.g., Kendall
et al, 2004).

A number of studies have tried to identify factors that may influence

treatment efficacy. There is little evidence that outcome is different when treatment

Table F.1.2 Sessions and components of the Cool Kids program.

Session Coverage - Child Coverage - Parents

1 Psychoeducation
2 Cognitive restructuring
3 Cognitive restructuring practice
4 In vivo exposure and development of hierarchies
5 Dealing with difficulties in exposure
6 Practice exposure and cognitive restructuring
7 Introduce assertiveness and social skills
8 Teasing and bullying
9 Practice and review
10 Practice, review and relapse prevention
Psychoeducation and treatment rationale
Cognitive restructuring for both parent and child
Cognitive restructuring practice
Child management skills
In vivo exposure and development of hierarchies
Dealing with difficulties in exposure
Practice exposure, cognitive restructuring and child
management
Ways to increase assertiveness and social skills
Teasing and bullying
Practice and review
Practice, review and relapse prevention

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Table F.1.3 Treating childhood anxiety disorders in practice

• First line treatment: Low-intensity treatment – including use of books

(bibliotherapy), CD’s or internet programs (e-therapy). May not be recommended in
cases of highly urgent need (e.g., chronic school refusal) or high risk (e.g., suicidal
ideation), or in cases of especially poor parent-child relationships

• If unwilling to attempt low intensity – then low-intensity is not recommended

– or patient does not improve with low-intensity treatment, suggest traditional
CBT or skills-based treatment with a qualified practitioner in all cases, with the
exception of patients who refuse skills-based treatment or CBT is not available

• If a patient does not improve after a treatment program delivered by a skilful

clinician for long enough (12-20 weeks), refuses skills-based treatment or CBT is not
available, consider medication

• When patients are treated with medication – alone or in combination with CBT
(multimodal treatment) – keep in mind that:
− No medication is approved by the US Food and Drug Administration (FDA)
for any anxiety disorder in patients younger than 6 years of age (see Table
A.8.1). Overall, avoid medication in younger children (i.e., younger than 10
years of age).
− While there is some evidence of effectiveness for some SSRIs for several
anxiety disorders (e.g., OCD, social phobia, generalised anxiety) (see
Table A.8.1), they are formally approved by the FDA in the US only for the
treatment of OCD (that is, they are used “off label” for anxiety disorders
other than OCD). This may not be the case in other countries.
− Avoid using benzodiazepines. While benzodiazepines reduce anxiety
in the short term, there is no evidence they are effective treating the
disorder. They have more side effects in young people and potential for
dependence.
Click on the picture to hear
− Monitor side effects, particularly suicidality. Professor Rapee talk about
anxiety disorders (06:08)
− Review regularly, initially weekly, later on monthly.
− Monitor response using an appropriate rating scale and switch to another
SSRI if there is no improvement or, if not already tried, add CBT.

is delivered in either a group or individual format. A more important issue that has
received some attention is the extent to which it is necessary to include parents and
to teach them specific skills in treatment. Evidence on this issue has been mixed
but generally indicates some, although small, benefits of including parents as active
participants in the treatment (Creswell & Cartwright-Hatton, 2007). However,
studies that have addressed this issue have rarely taken the age of the child into
account. As might be expected, the hints in the literature suggest that including
parents in treatment is likely to be relatively important in the treatment of younger
children, but shows little benefit in the treatment of adolescents (Barrett et al,
1996).
Another relevant question is the influence of comorbid diagnoses on
treatment effects. Surprisingly, the majority of research to date has failed to show
that treatment response is worse for anxious children with comorbid disorders.
In other words, anxious children seem to respond equally well to skills-based
treatment packages even if they have additional difficulties with anxiety, depression,
or externalising problems (Ollendick et al, 2008). Having said that, there is mixed
evidence for depression; a few studies have suggested that comorbid depression may
reduce treatment response (Rapee et al, 2009). A recent study from our own clinic

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has shed a little more light on this issue. Based on our data, it appears that having
a comorbid disorder does not influence the degree of change across treatment but
does influence the endpoint. Because children with comorbid disorders (especially
comorbid externalising disorders and depression) typically have more severe
anxiety to begin with, the point they reach at the end of treatment is generally not
as good as children without comorbid disorders, although the degree of change
across treatment is very similar. Some recent research has also begun to show that
children with high functioning autism and comorbid anxiety also respond very
well to treatment of their anxiety (Moree & Davis, 2010).
Few other predictors of treatment response have been found. There have
been hints that parent psychopathology, both parent anxiety and depression,
predicts worse outcome, but some studies have failed to show this effect. Other
factors such as marital status, parent education, and family size appear to have little
effect. One very recent study showed that genetic status might predict treatment
response. Children with short alleles on the 5HTTLPR gene showed a better
response to treatment at follow-up than did children with two long alleles (Eley et
al, in press). Naturally, this very interesting finding needs replication.
A program example: Cool Kids
There are several skills-based treatment packages for the management of
anxiety disorders in young people and most contain very similar components. To
provide an example, I will describe our own program, Cool Kids. Cool Kids is a
manualised treatment program for anxious young people aged 7-17 years. There
is a detailed set of guidelines for therapists that is supported by workbooks for
the parent and the young person. Different workbooks and a slightly different
structure are used for younger (7-12) and older (13-17) children. There are
also modified versions for use with children with autism, for adolescents with
comorbid depression, and for families who are unable to attend a clinic for face-
to-face treatment.
Treatment using Cool Kids generally comprises 10 sessions over 12 weeks.
Parents are an integral component and are seen at all sessions when treatment is
with children but have a slightly reduced involvement when treatment is with
adolescents. The program can be delivered in either group or individual format.
Sessions typically last 60 minutes when delivered individually and 120 minutes
when delivered as a group. There are separate components covered with children
and parents. The sessions and components of Cool Kids are shown in Table F.1.2.
Overall efficacy for Cool Kids is good and, as described above, there are
few negative predictors. We generally include any child with an anxiety disorder as
their principal (most interfering) disorder, including children with OCD, and we
rarely exclude children due to comorbidity. Our data indicate few differences in
outcome. In fact the only group who seems to respond slightly worse to treatment
is young people with social phobia. Therapists with training in clinical psychology,
experience in working with young people, and skills in the delivery of cognitive
behavioural treatments are able to run the program; training workshops are
regularly conducted through our centre. At present, manuals have been translated
into several languages including Spanish, Korean, Chinese, Turkish, and some
Scandinavian languages.

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PREVENTION AND EARLY INTERVENTION

Given the growing knowledge of risk factors for the development of child
anxiety, interest has begun to rise into the possibility of very early intervention and
prevention. In addition, growing recognition of the public health implications of
psychopathology has increased the realisation that a large proportion of children
who are high in anxiousness but do not meet criteria for an actual disorder may
nevertheless be suffering and endure restrictions on their lives. As a result, recent
work has begun to evaluate programs for prevention and early intervention of
anxiety (Lyneham & Rapee, in press). These programs have covered all levels of
intervention: universal, selective and indicated.
Several large trials have demonstrated the efficacy of anxiety management
programs applied universally across sub-populations obtained via schools. These
programs typically cover similar skills to those found in clinical packages including
education, relaxation, cognitive restructuring, and in-vivo exposure; often they
include additional skills such as communication and problem-solving. Therefore,
they may be better thought of as broad emotional health programs that aim to teach
young people ways of managing all distressing emotions. Results have been slightly
inconsistent, but have mostly indicated reductions in anxiety, usually with small
effect sizes (Bayer et al, 2009). Given that these are universal programs and are
not targeting high risk groups, large effects are not expected and even small effects
across an entire population are meaningful.
Selective anxiety programs refer to those that target children who report
moderate to high symptoms of anxiety but do not necessarily meet criteria for a
disorder. The presumption is that these children are at increased risk to develop
disorders in the future and hence teaching them anxiety management skills provides
a clear method of prevention. However, even if they do not go on to develop
anxiety disorders, the low to moderate distress and life interference experienced
by these children makes them a valid target for skills training, especially given that
very few have sought professional help. As with universal programs, the majority
of these interventions have used school-based populations. There are many
methods of selecting children with high levels of anxiety, but most trials so far
have used a combination of student self report and teacher report. Once again, the
content of these programs is very similar (or identical) to that of clinical treatment
programs. Results have mostly indicated significant reductions in anxiety following
intervention, generally with moderate effect sizes (Mifsud & Rapee, 2005). Some
research has shown continued benefits up to two years following intervention
(Dadds et al, 1999).
Finally, a few studies have begun to investigate indicated programs for the
prevention of anxiety – i.e., programs aimed at children scoring high on anxiety
risk factors. Targeted children have most commonly been selected on the basis of
high levels of temperamental inhibition, but high parent anxiety has also been used
to identify relevant children. In the only longer term study to date, we developed
a modified version of Cool Kids called Cool Little Kids. The program is aimed at
parents of inhibited preschool-aged children and comprises 6 group sessions.
Components are mostly aimed at reducing parent overprotection and encouraging
in-vivo exposure for the children. By age 7, children whose parents attended the
program showed significantly lower levels of anxiety symptoms and fewer anxiety

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diagnoses compared to children whose parents received no training (Rapee et al,

2010).
CONCLUSION
The past two decades have seen a tremendous expansion in our knowledge
of the development and management of childhood anxiety disorders. Many
key issues remain to be evaluated and we still have a long way to go but we are
currently at a point where anxious children are recognised and can be thoroughly
assessed. We have treatments that work for the majority of patients and programs
are beginning to prevent the development of anxiety. Several promising areas of
research are just starting to grow and will hopefully provide further advances in the
coming years. These include:
• Better understanding of risk factors for anxiety through longitudinal
research
• Closer evaluation of gene-environment interactions in the
development of anxiety
• More understanding of peer interactions in anxiety and their
influence on its development
• Better methods of disseminating treatments, for example through
internet and distance (tele-health) programs
• Evaluation of novel improvements to treatment such as the use of
memory consolidation agents or cognitive bias modification.

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